Choose Your Exam Rules

The Hospitalist. 2008 May;2008(05):

May 1, 2008 | The Hospitalist

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She also is on the faculty of SHM’s inpatient coding course.

The 1997 Guidelines In Detail

Elements that physicians must document correspond to each organ system. Some elements specify numeric criterion that must be met to credit the physician for documentation of that element.

Constitutional

Measurement of any three of the following seven vital signs: sitting or standing blood pressure; supine blood pressure; pulse rate and regularity; respiration; temperature; height; and weight (may be measured and recorded by ancillary staff); and
General appearance of patient (development, nutrition, body habitus, deformities, attention to grooming).

Eyes

Inspection of conjunctivae and lids;
Examination of pupils and irises (reaction to light and accommodation, size and symmetry); and
Ophthalmoscopic examination of optic discs (size, C/D ratio, appearance) and posterior segments (vessel changes, exudates, hemorrhages).

Ears, Nose, Mouth, and Throat

External inspection of ears and nose (overall appearance, scars, lesions, masses);
Otoscopic examination of external auditory canals and tympanic membranes;
Assessment of hearing (whispered voice, finger rub, tuning fork);
Inspection of nasal mucosa, septum, and turbinates;
Inspection of lips, teeth and gums; and
Examination of oropharynx: oral mucosa, salivary glands, hard and soft palates, tongue, tonsils, and posterior pharynx.

Neck

Examination of neck (masses, overall appearance, symmetry, tracheal position, crepitus); and
Examination of thyroid (enlargement, tenderness, mass).

Respiratory

Assessment of respiratory effort (intercostal retractions, use of accessory muscles, diaphragmatic movement);
Percussion of chest (dullness, flatness, hyperresonance);
Palpation of chest (tactile fremitus); and
Auscultation of lungs (breath sounds, adventitious sounds, rubs).

Cardiovascular

Palpation of heart (location, size, thrills);
Auscultation of heart with notation of abnormal sounds and murmurs; and
Examination of carotid arteries (pulse amplitude, bruits); abdominal aorta (size, bruits); femoral arteries (pulse amplitude, bruits); pedal pulses (pulse amplitude); and extremities for edema and/or varicosities.

Chest (Breasts)

Inspection of breasts (symmetry, nipple discharge); and
Palpation of breasts and axillae (masses or lumps, tenderness).

Gastrointestinal (Abdomen)

Examination of abdomen with notation of presence of masses or tenderness;
Examination of liver and spleen;
Examination for presence or absence of hernia;
Examination (when indicated) of anus, perineum, and rectum, including sphincter tone, presence of hemorrhoids, rectal masses; and
-Obtain stool sample for occult blood test when indicated.

Genitourinary

Male

Examination of the scrotal contents (hydrocele, spermatocele, tenderness of cord, testicular mass);
Examination of the penis; and
Digital rectal examination of prostate gland (size, symmetry, nodularity, tenderness).

Female

Pelvic examination (with or without specimen collection for smears and cultures), including:

Examination of external genitalia (general appearance, hair distribution, lesions) and vagina (general appearance, estrogen effect, discharge, lesions, pelvic support, cystocele, rectocele);
Examination of urethra (masses, tenderness, scarring);
Examination of bladder (fullness, masses, tenderness);
Cervix (general appearance, lesions, discharge);
Uterus (size, contour, position, mobility, tenderness, consistency, descent or support); and
Adnexa/parametria (masses, tenderness, organomegaly, nodularity).

Lymphatic

Palpation of lymph nodes in two or more areas:

Neck;
Axillae;
Groin; or
Other.

Musculoskeletal

Examination of gait and station;
Inspection and/or palpation of digits and nails (clubbing, cyanosis, inflammatory conditions, petechiae, ischemia, infections, nodes);
Examination of joints, bones and muscles of one or more of the following six areas: head and neck; spine, ribs and pelvis; right upper extremity; left upper extremity; right lower extremity; and left lower extremity. The examination of a given area includes:
Inspection and/or palpation with notation of presence of any misalignment, asymmetry, crepitation, defects, tenderness, masses, effusions;
Assessment of range of motion with notation of any pain, crepitation or contracture;
Assessment of stability with notation of any dislocation (luxation), subluxation or laxity; and
Assessment of muscle strength and tone (flaccid, cog wheel, spastic) with notation of any atrophy or abnormal movements.

Skin

Inspection of skin and subcutaneous tissue (rashes, lesions, ulcers); and
Palpation of skin and subcutaneous tissue (induration, subcutaneous nodules, tightening).

Neurologic

Test cranial nerves with notation of any deficits;
Examination of deep tendon reflexes with notation of pathological reflexes (Babinski); and
Examination of sensation (by touch, pin, vibration, proprioception).

Psychiatric

Description of patient’s judgment and insight; and
Brief assessment of mental status including orientation to time, place, and person; recent and remote memory; and mood and affect (depression, anxiety, agitation).—CP